Skills remix an unpopular fix

Nurses say consultants’ idea to shuffle workforce roles isn’t the answer for overworked staff. 

Public hospitals could save up to $430 million a year by making better matches between workers and their work, a new report states.

Co-authors Grattan Institute health program director Stephen Duckett and senior associate Peter Breadon said that doctors, nurses and allied health professionals are “squandering their valuable skills on work that other people could do”.

The report, Unlocking skills in hospitals: better jobs, more care, puts forward workforce changes that the authors have said could help alleviate the significant pressure on Australian hospitals.

“It doesn’t take 15 years of training to provide light sedation for a stable patient having a simple procedure, or a three-year degree to help someone bathe or eat, but that’s where we are now,” Duckett said. “Current workforce roles were designed in the days of the horse and buggy. The choice to update them should be easy, because it means more and better care, more rewarding jobs for health professionals and a more sustainable system.”

However, the report has generated concerns from the nursing profession.

ANMF federal secretary Lee Thomas said the findings are not the solution to Australia’s nursing shortage and future demand for health services.

“[We] accept that better workforce planning is essential,” she said. “There is no doubt that there is a nursing shortage, but our view is that this [report’s recommendations are] not the answer.

“We can’t ignore the fact that if hospital administrators and state governments were employing more graduate nurses, outcomes like this would, most likely, not be required.”

Free up the nurses

Nursing assistants could be used to free up time by providing basic care for patients, the report states. It proposes a situation whereby nursing assistants would make up 15 per cent of the nursing workforce, and would be responsible for six particular tasks: stocking medications; clerical work; making beds; moving/turning patients; feeding and bathing.

Duckett believes there are two main benefits of this type of model.

“First, it would help to make the health system sustainable into the future, it is a cost-effective way of meeting the increase in care needs associated with growth in demand,” he said. “The changes we propose would mean an additional 70,000 patients could be treated for the same money.

“Secondly, it would make nurses’ jobs better. They would have more time for the complex work that uses the full range of skills they have acquired with their education and experience.”

Thomas said this part of the report relies on a superficial reduction of tasks to determine the allocation of care.

“While nursing assistants are a very valuable and important part of the nursing family, what this report does is it ignores the true complexity of care provided in acute hospitals today,” she said. “It uses quite unsophisticated analysis and a very simplistic approach to the provision of nursing care and it accepts without question that nursing cannot be provided by the available nursing labour force currently in place.”

She said the report also fails to put any boundaries around how you contain the nursing assistant’s scope of practice to the six allocated tasks.

Christine Duffield, professor nursing and health services management at University of Technology, Sydney, found issue with some specific details of the report. For example, she said that in most places nursing assistants already make up 15 per cent of the nursing workforce.

Duffield, who is now involved in the first study to show the impact to patient outcomes of adding a nursing assistant to the workforce, commented on the report’s suggestion to substituting registered nurses with AINs.

“If you are substituting, then it makes the workload of those regulated workers left higher, she said. “[However], if you add the AIN, it would decrease the workload and it would be useful in rounding, and it probably would improve patient outcomes.”

Regarding the suggestion in that report that personal care is often rushed, delayed or not done, Duffield said the authors have missed the point.

“Those tasks were not done because there was insufficient staff and the workload was too heavy to get them done in the time allocated,” Duffield said. “[This model] does not change the amount of work, in fact it makes the workload of these skilled nurses perhaps a bit heavier because they are going to have to supervise the AINs.”

Both Thomas and Duffield agreed with the report’s call for a nationally consistent education framework.

As Thomas said, “We [ANMF] absolutely agree with the report in this regard; however, there must be a regulatory framework that ensures minimum standards of education and a limited and confined scope of practice for nursing assistants. The regulatory framework must also include registration/licensing via existing mechanisms.” She said it is only through such mechanisms that the protection of the public can be assured.

Duckett suggests nursing assistants should be prepared to a Certificate 3 or 4 level.

Specialist nurses do common, low-risk procedures

The second model the report proposed looks at tasks that are traditionally reserved for doctors, but that could be undertaken by specialist nurses.

Duckett and Breadon point to trials in Australia as well as years of overseas experience that suggests less highly trained staff are able to perform certain tasks and procedures now done by doctors and nurses.

In particular, the report focuses on endoscopy nurses, as well as nurses providing sedation and anaesthesia.

“Many studies show that experienced nurses can readily learn to perform specific procedures well, safely and with high patient satisfaction,” Breadon wrote in a recent article. “In the United Kingdom, nurses perform around one in every seven endoscopies. In the United States, nurses routinely deliver anaesthesia.

“Yet even thought similar roles have been tried in Australia with good results, there are very few endoscopy and sedation nurses.”

Professor Glenn Gardner, faculty of health, Queensland University of Technology, said procedures such as endoscopies and sedation were well within the scope of practice for a registered nurse.

However, she was quick to reiterate that due to the complexity of the procedures “there needs to be some acknowledgement that nurses need to work at an advanced practice level – in a way that takes practice beyond that of a foundation registered nurse”.

She agrees with Duckett that Australian training facilities for such procedures are excellent but said these types of procedures require more than technical skills.

“You need more comprehensive education around decision-making – the assessment activities, the follow up afterwards – and unless that is incorporated around these procedural activities, you might as well just get a technician,” Gardner explains. “We have got a lot of evidence over decades that patients value what nursing brings to their healthcare.

“Learning a task or procedure doesn’t create an advanced practice nurse, and I think overall it demonstrates a lack of respect for the healthcare consumer.”

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